Do Not Attempt Resuscitation (DNAR) – The Role of the School Nurse
It is the position of the National Association of School Nurses (NASN) that each student with a Do Not Attempt Resuscitation (DNAR) order have an Individualized Healthcare Plan (IHP) and an Emergency Care Plan (ECP) developed by the registered professional school nurse (hereinafter referred to as school nurse) with input from parents or guardians, the student’s healthcare provider, the palliative care team, administrators, teachers, local emergency medical services, local funeral director and, when appropriate, the student in order to support the student’s access to education and palliative health care. Furthermore, a DNAR order for a student should be evaluated individually at the district level with input from the school district’s legal counsel for consideration of state and local laws.
Families today face many issues but none more sensitive and emotionally challenging than an order for DNAR. A DNAR order is not abandonment of medical treatment and does not rescind any obligation to provide quality care; rather it is part of the management plan. This plan is reviewed by the healthcare provider with the family to communicate the difficult decision to refrain from life sustaining treatment that is determined by the healthcare provider and family to be ineffective or that the risks would outweigh the benefits. A DNAR medical order for the school should be implemented in the context of palliative care, including comfort measures as well as addressing emotional and spiritual needs (AAP, 2010).
In a 1974 statement, the American Heart Association declared that cardiopulmonary resuscitation (CPR) was not indicated for all patients. Individuals with terminal, irreversible illnesses where death is the expected outcome do not necessarily merit CPR. In 1994 the American Academy of Pediatrics (AAP) and the National Education Association (NEA) issued guidelines on foregoing life‐sustaining CPR for children and adolescents (AAP, 2010). Originally, the medical order was referred to as a Do Not Resuscitate order (DNR), which evolved to Do Not Attempt Resuscitation (DNAR), and sometimes Allow Natural Death (AND) (Selekman, Bochenek & Lukens, 2013). Currently, the order to provide comfort care is part of a much broader palliative care plan, which may include Medical Orders for Life Sustaining Treatment (MOLST) (APA, 2010). In the case of ABC School v. Mr. and Mrs. M, in Massachusetts, the court ordered the school to honor the DNAR order for a medically fragile child. In addition, the court refused to allow the school to shield staff from liability should they choose not to honor the DNAR order (Adelman, 2010).
Chronic health conditions that involve special healthcare needs affect an estimated 19.2% (14.2 million) school‐age children (Bethell et al., 2011). The AAP (2010) estimates that, on any given day, there are 2,500 adolescents and 1,400 preadolescents who are within 6 months of dying from their chronic condition, such as end-stage heart, liver, kidney disease and cancer (Adleman, 2010). According to a Centers for Disease Control and Prevention survey, the percentage of schools where health services staff reported the need to follow a DNAR order increased from 29.7% in 2000 to 46.2% in 2006 (AAP, 2010).
Growing populations of students with chronic health conditions ‐‐ including terminal and irreversible illnesses, congenital defects, injuries, and malignancies, where death may be the expected outcome ‐‐ are now routinely attending school (Klick & Hauer, 2010; Adelman, 2010). Children with special healthcare needs are entitled to a free and appropriate education in the least restrictive environment (U.S. Dept. of Justice, 2005). Whenever possible, students with chronic or terminal conditions belong in school in order to access their education. Students benefit from the psychosocial and emotional benefits of interacting with peers and maintaining their daily routine (Klick & Hauer, 2010). Because state and local laws and regulations vary regarding DNAR orders for students, each palliative care request must be reviewed by the school team with leadership from the school nurse in order to provide the best care possible in the school setting for the student (AAP, 2010). The school nurse and staff should focus on what can be provided for comfort rather than on what is not being provided. In addition, it was found in a recent NASN discussion list inquiry that deaths of students with DNAR orders often did not occur at school. (Zacharski et al., 2013).
Development and implementation of the IHP are the responsibility of the school nurse and are supported by the AAP (AAP, 2008). The development of the IHP requires the school nurse to do the following:
Work collaboratively with the school team (the family, school psychologist, the school guidance counselor, administrators, teacher, and members of school crisis teams).
Communicate and coordinate the development of the school plan with all members of the student’s healthcare team that may include the family, pediatrician, social worker, child life specialist and palliative care team members (Klick & Hauer, 2010).
Participate as an essential member of team in the development of the Section 504 plan or the IEP plan, communicating the plan and the IHP to school staff while maintaining student confidentiality to the extent requested by the student/family. This plan should minimally be reviewed annually or sooner if required.
Coordinate emotional support for staff utilizing school district and community resources, including bereavement services for the school community in collaboration with the palliative care team, school team and community mental health resources (Klick & Hauer, 2010).
Components of the IHP include but are not limited to:
A written DNAR request from the parent(s) as well as the healthcare provider’s written DNAR order that is acceptable per state regulations. A court order may be required (Selekman, Bochenek, & Lukens, 2013);
Acceptance of DNAR orders vary according to state regulations.
The DNAR request should have a clearly delineated date (some orders are rescinded while in hospital or otherwise. Many DNARs need to be reordered as deemed by the medical facility or state regulations). Some DNAR orders are issued for short periods of time and need to be renewed within a few weeks.
An original DNAR order or a copy of the order on the appropriate state EMS Palliative Care/DNAR order form may be required.
A state authorized Out of Hospital Do Not Resuscitate bracelet or necklace may also be accepted by Emergency Medical Services.
The DNAR order may be revoked at any time verbally or in writing by the parent/guardian (Zacharski et al., 2013).
Comfort measures which may include holding, positioning, oxygen administration, pain and bleeding control (Selekman, Bochenek, & Lukens, 2013);
Who will do the pronouncement of death (physician, nurse practitioner or physician assistant)? In some states, pronouncement of death becomes a concern in the school setting; i.e. the local EMS may not be able to remove the body if death has already occurred. If this happens, arrangements must be made as to who will arrive promptly to pronounce death so that the body can be removed from the school as soon as possible;
School nurses play a pivotal role with respect to DNAR orders as well as the delivery of health care (AAP, 2010; Klick & Hauer, 2010). In addition, the school nurse is the school health professional with the knowledge, experience and skills to coordinate the care for a student with a DNAR order, linking the school with the medical and community services needed by the student, while advocating for the student and family to ensure access to a free and appropriate education (Selekman, Bochenek, & Lukens, 2013).
Adelman, J. (2010). The school-based do-not-resuscitate order. DePaul Journal of Health Care Law, Winter, 197 214.
American Academy of Pediatrics. (2010). Policy statement: Honoring do-not-attempt resuscitation requests in schools. Pediatrics, 125, 1073-1077. doi: 10.1542/peds.2010 0452
American Academy of Pediatrics. (2008). Role of the school nurse in providing school health services. Pediatrics, 121, 1052-1056. doi: 10.1542/peds.2008.0382
Bethell, C.D., Kogan, M.D., Strickland, B.B., Schor, E.L., Robertson, J., & Newacheck, P. (2011). A national and state profile of leading health problems and health care quality for US children: Key insurance disparities and across-state variations. Academic Pediatrics, 11(3), 22-33. doi: 10.1016/j.acap.2010.08.011
Klick, J. C., & Hauer, J. (2010). Pediatric palliative care. Current Problems in Pediatrics and Adolescent Health Care, 40 (6), 120-151. doi:10.1016/j.cppeds.2010.05.001
Morgan, D. (2009). Caring for dying children: Assessing the needs of the pediatric palliative care nurse. Pediatric Nursing, 35 (2), 86-90.
Selekman, J., Bochenek, J., & Lukens, M. (2013). Children with chronic conditions. In J. Selekman (Ed.), School nursing: A comprehensive text (2nd ed., pp. 700-783). Philadelphia, PA: F.A. Davis Company.
U.S. Department of Justice, Civil Rights Division (2005). A guide to disability rights laws. Retrieved from http://www.ada.gov/cguide.htm
Zacharski, S., Minchella, L., Gomez, S., Grogan, S., Porter, S., & Robarge, D. (2013). Do not attempt resuscitation (DNAR) orders in school settings: Special needs school nurses review current research and issues. NASN School Nurse, March, 71-75.
Acknowledgment of Authors:
Christine M. Tuck, MS, BSN, RN, NCSN
Alicia Jordan, BSN, RN, NCSN
Patrice Lambert, MSN, RN, SNC
Jessica Porter, BSN, RN, NCSN
Acknowledgement of 2012 Issue Brief Authors:
Marie DeSisto, MSN, RN
Susan Zacharski, MEd, RN
Kay Kurbjun, MSN, RN
Janice Selekman, DNSc, RN, NCSN
Adopted: January 2014
This document replaces the Issue Brief Do Not Resuscitate (Adopted June 2012).
All position statements from the National Association of School Nurses will automatically expire five years after publication unless reaffirmed, revised, or retired at or before that time.